Laparoscopic Duodenojejunostomy for Superior Mesenteric Vein Syndrome Associated with Nutcracker Phenomenon: The First Case Report
Challenging differential diagnosis, Diagnostic / therapeutic accidents, Unusual setting of medical care, Rare co-existance of disease or pathology
Khaled S. Ahmad, Naif A. Alenazi, Mohamed S. Essa, Mahir S. Alrushdan, Abdulbaset M. Al-Shoaib
(Department of General Surgery, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabia)
Am J Case Rep 2019; 20:1108-1113
Duodenal compression between the superior mesenteric vessels and aorta or its branches is a rare disease in which the angle between the superior mesenteric vessels and aorta becomes acute, resulting in duodenal obstruction. Reduction in retroperitoneal fat due to several debilitating conditions is considered to be the cause of the decreased angle between the 2 vessels. Nutcracker phenomenon is the asymptomatic compression of the left renal vein (LRV) between the aorta and the superior mesenteric artery.
CASE REPORT: We report the case of a 33-year-old man who presented with postprandial abdominal pain, mainly at the epigastric region, colicky in nature, without radiation, accompanied by nausea, postprandial vomiting, and loss of weight. Computed tomography (CT) of the abdomen showed duodenal compression between the SMV and the right common iliac artery, which has never been reported before. Laparoscopic duodenojejunostomy was performed.
CONCLUSIONS: Vascular compression of the duodenum presents with manifestations of proximal small bowel obstruction, which may have chronic, intermittent, or acute symptoms. Diagnosis is difficult due to the lack of knowledge of this rare disorder. Most of these symptoms can be present in other diseases, and symptoms sometimes do not correspond with imaging findings. Therefore, for a better outcome, the clinician should have a high index of suspicion and should be able to exclude other causes with similar manifestations.
Keywords: Duodenal Obstruction, Mesenteric Veins, Renal Nutcracker Syndrome